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2004-565 TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201 Community Development - Building & Codes (518) 761-8256 CEllTIFICATE OF COMPLIANCE Permit Number: P20040565 Date Issued: Thursday, July 22, 2004 This is to certify that work requested to be done as shown by Permit Number P20040565 has been completed. Tax Map Number: 523400-308-016-0001-078-000-0000 Location: 4 MINNESOTA Ave Owner: TERESA K NICHOLSON Applicant: TERESA K NICHOLSON This structure may be occupied as a: By Order of Town Board Septic Alteration Residential TOWN OF QUEENSBURY r: Director of Building&Code Enforcement TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20040565 Application Number: A20040565 Tax Map No: 523400-308-016-0001-078-000-0000 Permission is hereby granted to: TERFSA K NIC;HOLSON For property located at: 4 MINNESOTA Ave in the Town of Queensbury,to construct or place at the above location in accordance with application together with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning Ordinance. Type of Construction Value Owner Address: TERESA K NICHOLSON 4 MINNESOTA Ave Septic Alteration Residential Total Value QUEENSBURY, NY 12804 Contractor or Builder's Name /Address Electrical Inspection Agency FRED SMITH 23 VERMONT Ave OITEENSBITRY_ NY 12804 Plans&Specifications 2004-565 SEPTIC ALTERATION $25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, July 22, 2005 (If a longer period is required,an application for an extension must be made to the code Enforcement Officer of the Town of Queensbury before the expiration date.) Dated at th of QnffAnsIbury, hursday, July 22, 2004 SIGNED BY for the Town of Queensbury. Director of Buil mg&Ade Enforcement Application for Permit—Septic Disposal System Town of Queensbury 742 Bay lioad Queensbury,NY 12804 (518).761-8256 1. OWNER INFORMATION: If YYI� n1� �So ..Orficc Use ................. Location of installation: �'1` �� t A, Tax Map No. / / , File Permit No. ' h / H Z t'C�/1tJlsv�� Fee Paid Owner's Name: Ave 2. INSTALLER'S NAME vll PHONE NO. .. 3. -RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply N of bedrooms with applicable gallons per bedroom to equal total daily flow) Year of House$ No of Bedrooms x Computation = Total Daily Flow 1980 or-older %{. x 130 gaVbdnn _ 3w 1980— 1991 x 130 gal/bdrm = _. 1991 —present x _110 gaVbdrm = Garbage Grinder Installed yes / no Spa or Whirlpool Installed yes / no CEwE® 4;, PARCEL INFORMATION:" (circle applicable informak�ippn td�o&measurements) 4.il Np&j_t9 Q.�QU�t4I atv.r_1!004 DAB � M. IV Ot!;'MA(.Qd,t1 ...... _. :ttor_$uprly Yat sal at what depth '�lVf�Rolling loam Jcet UIL fc�ctr we Steep slope clay if well; water supply slope other from any septic-system depth: absorption is f1. other Percolation Test: (To be completed by licensed prr fesslonal engineer or architect) Rate: minute per Inch S, PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by n licensed professional engineer or architect(unless installed in a Planning Board approved subdivision). Add 250 gallons to the size of the septic lank and Icach field for cacti Garbage Grinder, Spa or Whirlimol 7'ub. Septic Tank: gallon (min, size 1,000 gal.) Tile Field: each trench _J?. Total System Length t f?. Seepage Pit(s): number of size vfeach: J?. by J?. Size of Stone to be used: tl ��_ / �lrpth or,thickness Bed System Size: x Ahemadve System: length and/or size 6. HOLDING TANK SYSTEM: (if required) . Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons Note: Alarm System and associated electrical work must be inspected by a Town approved electrical inspection agency- 7, SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON(please read) For your protection, please note that pursuant to Section-'136-29 of the Code of the Town of Queensbury, any permit or approval granted which is based upon or is granted in reliance upon any material misrepresentation or failure to make a material fact or circumstance known by or on behalf of an applicant, shall be void. I have read the regulations with respect to this application and agree to abide by those and all requirements o T of Queensbury Sanitary Sewage Disposal Ordinance. Slg ature o responsible person Date Septic Inspection Report Office No. (518) 761-8256 Date Inspection request received: �( 99� Queensbury Building&Code Enforcement Arrive: amlk4e art: am/pm 742 Bay Rd., Queensbuly,NY 12804 Inspector's Initials: NAME: PERMIT NO.: LOCATION: UMMp 6 b: INSPECT ON: 1221dj () JL RECHECK: Comments and/or diagram Soil T Sa la T e of Vva—terk Munic /Well Water Waterline separation distance ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Length of each trench ft. Depth of trenches ft. Size of Stone 7-- Seepage Pits: Number Size: x Stone Size: Pipin2 Size Type Building to tank VSc Tank to Distributi n Box tt 5 rL 3S-- Distribution BoxtONield/Pit tlfj Zd Opening Sealed Y N/Partial Location/Separations Foundation to tank ft. Foundation to absorption ft. Separation of Pits ft. Confornis as per Plot Plan Y N Location of Syste on Property: Front e Left Side Right Side Middle Front iddle Rear S stem Use Stat Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved LAS ueHemingway\Building.Codes.Inspection.FORMS\S ep tic Inspection Report.doc January 28,2003 (Mlml "I have seen or observed, or believe I saw evidence of, ail objects such as houses, :ie!ls, trees, fences, etc., shown oil this OCUrilent. i also represent that I have perso��aliy ;r d t1.e istances set forth on the diagram." SIGNATURE DATE v_ RE EIV y ' JIIL� 200 U TOWN F --!U_1L1 f NG AND CO E Y Ep ■ F t. ,t..VVEU 6y CICr.�.y f�